Residence Hall and Roommate Preference Form - Public.coe.edu ...

ESL and TSAResidence & Roommate FormCOE COLLEGE ENGLISH AS A SECOND LANGUAGE PROGRAMResidence Hall and Roommate Preference FormThe following questionnaire will assist us in placing you in the residence hall and matching you with roommates. Wewill do our best to place you with compatible roommates, based on this information._________________________________Last name______________________________________First NameMale or Female __________Date of Birth ____________________ Age ________month/ day/ year_____________________________________________________________________________Home address - Number and streetHome phone_____________________________________________________________________________City Country Zip1. Smoking Preference (ALL residence halls are smoke-free.)Do you smoke? _____yes _____no2. Current Sleeping HabitsOn weekdays I like to get up… _____early _____lateOn weekends I like to get up… _____early _____late3. I function better……. _____in the morning ______in the evening4. I prefer to study…. _____alone ______with others5. I plan to study mostly: _____in my room ______in the library_____other6. Tell us about your study habits. (Check all that apply to you.)_____I require absolute quiet and am easily distracted._____I like low background noise or music._____I am able to tune out most noises and am not easily distracted._____I follow a schedule or regular study routine._____I study mainly near the time of a test or when a project is due.7. The kind of music I most enjoy listening to is: (Check all that apply.)_____ Classical ______Rock _______Rhythm & Blues_____Jazz ______Rap _______Alternative_____Country ______Pop _______Japanese Pop_____Other?1

8. I have a physical/medical condition that requires consideration. (Please explain.)_____Yes_____No______________________________________________________________________________________________________________________________________________________________________________________________________________________________9. What types of free-time activities have you been involved with in the past, and what activities atCoe College are you interested in exploring?10. Is there anything else you would like to tell us about yourself?Please return this form to:Barbara J. Drexler or Joanna Shaver, E.S.L. Department, Coe College1220 First Avenue N.E.Cedar Rapids, Iowa 52402 U.S.A.2